CMS Issues Guidance for Federal Monitoring Surveys

It’s that time of the year where the Centers for Medicare and Medicaid Services (CMS) issues an Admin Memo regarding Long Term Care (LTC) Federal Monitoring Surveys (FMS). Federal Monitoring Surveys are required for CMS locations to validate health, Life Safety Code and Emergency Preparedness survey processes. In this post, we’ll look at what’s required for the Long-Term Care Survey Process, as that’s what’s used for the health survey process.

LTC Health Federal Monitoring Surveys Overview

Have you seen an influx of survey teams that include a Federal surveyor since the start of the new Fiscal Year (FY)? That’s likely because Federal surveyors are performing Resource and Support Surveys (RSS), which CMS recommends are completed in the first six months of the FY. However, RSS can be conducted at any time during the FY in order to provide instructions, support, guidance and education to State surveyors to ensure they conduct thorough investigations for focused concern areas.

Resource and Support Surveys (RSS)

Resource and Support Surveys are used for assessment of State Agency survey team performance, and performance related to specific areas of concern (more on that below). The Federal surveyor who accompanies the team is allowed to provide training and/ or technical assistance while onsite during the survey process. The Federal surveyor can be part of an initial, standard, revisit or complaint survey team. The Federal surveyor will tag along with the surveyors during a survey while they make observations and conduct interviews related to areas of concern. The Federal surveyor is expected to discuss the surveyor’s findings and assist the surveyor will applying the findings to the regulatory requirements. The Federal surveyor will use the LTCSP resources, including Appendix PP of the State Operations Manual (SOM) and Appendix Q of the SOM, as well as the survey pathways. The Federal surveyor is responsible for ensuring that the survey teams use the LTCSP Procedure Guide when conducting the survey.

The goal of the RSS is to assist the survey team and provide education related to survey learning opportunities. The Federal surveyor provides an FMS Health RSS Report to the State Agency with documentation of the survey findings and a written summary of what feedback was provided once the survey team made its compliance decisions. The Report is intended to serve as a learning tool for all State Agency surveyors so they can appropriately apply the Principles of Documentation. The survey team and survey performance are not evaluated during an RSS.

Health Comparative Surveys

Unlike the RSS, a Health Comparative Survey is a full survey conducted by Federal surveyors after a standard survey has been conducted by the State Agency survey team. The purpose of the comparative survey is to monitor and evaluate a SA’s performance on survey. This type of survey is conducted within 60 days of the completion of the State survey – so if you get a visit from a Federal team within a couple of months of your survey, that’s what’s going on. Each state is required to have 20% of its total mandated surveys be Comparative surveys.

Focus Concern Surveys (FCS)

In addition to the Resource and Support Surveys and Health Comparative Surveys, there is another type of survey that CMS locations have to conduct annually. Those are the Focused Concern Surveys (FCS). Focused Concern Surveys have been around for a few years now, and the “focus” changes based on issues CMS identifies through survey data and other information. The FCS is an independent investigation that is conducted by one or more Federal surveyor and focuses on the identified concern areas. Like the Health Comparative, the timeframe for completion is within 60 calendar days of the completion of a State Agency’s standard or complaint survey. However, these types of surveys are expected to be completed by a Federal Surveyor during the second six months of the FY. The Federal Surveyor will follow all of the investigative protocols and pathways for the focused concern areas in order to assess the effectiveness of the State Agency’s survey performance.

An FCS Health survey can occur after a standard or complaint survey. During this survey, the Federal surveyor will use 60% of the survey sample from a provider’s actual survey who were investigated for a concern area or LTCSP Care Area. The sample cannot exceed five residents per care area. After using the investigative protocols in Appendix PP and the Critical Element Pathways, the Federal surveyor makes his/her compliance decisions. An exit will be conducted with the Administrator and any other invited facility staff.

During the exit, if any of the Federal surveyor’s findings have been determined to be Substandard Quality of Care (SQC), Harm, or Immediate Jeopardy (IJ), the facility will be notified at the exit. A Statement of Deficiencies (2567) will only be developed if the Federal surveyor has identified a deficient practice for Nurse Staffing, Unnecessary Psychotropic Medications, or Facility-Initiated Discharge if the Federal surveyor’s finding was not identified by the State Agency’s survey team at that scope/severity.

It can get even worse than that. If the Federal surveyor has identified additional related areas of concern, those tags may be included (even if they haven’t been identified as SQC/ Harm/ IJ). A couple important things to note:

  • If SQC is identified during the FCS, the Federal surveyor will conduct a Partial Extended Survey, either immediately or within 14 calendar days after the completion of the abbreviated FCS where SQC was identified.
  • If Immediate Jeopardy is suspected, the Federal surveyor will follow the guidance in Appendix Q.
  • A 2567 will not be issued for findings with S/S of F or lower (not SQC or Harm/IJ), but sufficient information will be provided to the facility so it can correct the identified issues.
  • If the Federal surveyor does not identify any issues, the provider will receive a 2567 with the initial comments indicating there was an FCS, but no deficiencies were cited.

After the survey, an FCS Report is provided to the State Agency. The concern areas are rated (Met/ Partially Met/ Not Met). The State Agency can appeal the Not Met/Partially Met ratings.

LTC Health National Concerns (FY 2024 and FY 2025 Focused Concern Areas)

Not surprisingly, CMS has picked three areas that we know continue to be under scrutiny and always get a lot of media and watchdog attention. The first area is Nurse Staffing, which we know is one of the most frustrating areas for providers to address. The second area of concern is Unnecessary Psychotropic Medications, which is no surprise. The third area of concern, Facility-Initiated Discharges, has long been touted by State LTC Ombudsman as the complaint they hear most frequently. These are difficult areas for providers to get their hands around, but it’s time to get prepared, because surveyors will have their eyes on these areas on your next survey.

It’s also important to note that CMS may have identified a particular concern in your state, and that will trigger a Federal surveyor to investigate those identified concerns as well. Our data at CMSCG shows fluctuations in issues among the states, so it’s not unlikely that the State Agency may home in on a specific area of concern, including one that is related to the identified national concerns. For instance, in the CMSCG home base of New York, we are seeing an emphasis on all things related to medication storage and management – which has a tie-in to the national concern of Unnecessary Psychotropic Meds.

View the November 20, 2023 CMS Admin Memo, “Guidance for Federal Monitoring Surveys (FMS)” (Admin Info: 24-05-NH) for full details, including the number of surveys that will take place in your state.

Next up, we’ll take a look at Life Safety and Emergency Preparedness Federal Monitoring Survey (FMS) requirements. Preparing for your upcoming survey? CMSCG can help you prepare for good survey outcomes in an increasingly tough regulatory environment. Contact us today to schedule your mock survey (full team or focused) or learn about our other quality monitoring consulting services for nursing homes.

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